Clearing up the confusion: are nurse practitioners an appropriate primary care solution?
Recently there have been comments on this website and in other forums about nurse practitioners in the health care system and how we are not really an appropriate solution to primary care shortages for a whole bunch of reasons. While debate is usually healthy, the problem here is that many of the rationales given for not utilizing NPs in primary care are just not true: “NPs need to be supervised by doctors. Because NPs don’t own their own practices, they lack career-long commitments to our patients. NPs are cheaper, but not really a cost saving because they don’t see as many patients. And NPs spend longer with patients, and this makes them inefficient, not comprehensive.” Yikes – where do I start?!!!
Fallacy number one: NPs are supervised by physicians. No, we’re not. We do consult physicians when appropriate and when required by the crazy system of restrictions imposed on NP practice by the Ontario government, primarily at the behest of the physician lobbyists who from the beginning pushed for highly restricted NP practice.
For example, NPs are not allowed to order a bone mineral density test to look for osteoporosis. This is a test that uses so little radiation the technicians can stay in the room while the test is being done! How does prohibiting NPs from ordering this test serve patients? We can order x-rays of the knees, but not the hips. We can order ultrasounds of the abdomen, but not the shoulder. Until recently, we could only order blood tests from an approved list which allowed us to order, as an example, serum amylase (a pancreatic enzyme) but not serum lipase (a pancreatic enzyme). Only recently have restrictions been removed to allow us to prescribe medications for common conditions such as diabetes and hypertension. If all these restrictions don’t represent built in inefficiency, I don’t know what does.
Fallacy number two: NPs lack career-long commitments to their patients and tend to move around a lot. I inherited hundreds of my patients from the practices of two family doctors who left the community. The second had inherited many patients from the first, and stayed only two years!
Now the part about NPs being mostly salaried employees is true, and this is because the Ontario government allows essentially no other compensation mechanism for us. Unlike physicians, we cannot bill OHIP for the work we do.
The fee for service model does, as another commentator points out, reward high volumes of patients, which does not necessarily result in good quality care. I have seen patients whose lab tests confirm they have had diabetes for years, who have had no idea about that because it was never explained to them – or at least never explained in a way that allowed them to understand it. I have seen parents who are astonished when I ask them to undress their babies for a check up. They tell me “our old doctor never did that.” I guess doing a well baby visit without removing the baby from the snowsuit could be perceived as efficient, but you’d be hard pressed to call it comprehensive.
Fallacy number three: NPs are inefficient because they spend more time with patients. Now, I can understand why this would be important if NPs put together cars on an assembly line. But how did spending more time with patients become a health system liability? I see patients in 20 minute appointments (more for annual health exams and well baby/child visits). My physician colleagues book 15 minute appointments – so we’re in more or less the same ballpark. I need longer appointments because unlike the doctors I work with I do not have nursing assistance, I work out of one examination room only, I clean up the room between patients myself, and I need time to consult on ordering tests the government restricts me from ordering independently. (My physician colleagues will be ecstatic when these impediments to practice are finally removed).
I believe most family physicians provide excellent care, although the ones I’ve worked with over the years have tended to either be on salary in the community health centre system, or to book long enough appointments to be able to spend adequate time with their patients. I cannot comment on the high volume, book every five minutes style of practice doctors.
What I do know is that despite the government-imposed restrictions on our practice, NPs also provide excellent primary health care to thousands of Ontarians. Just ask our patients.